Director of Transitional Care & Utilization Management
Director of Transitional Care & Utilization Management
Location: United States
Why Work at AbsoluteCare?
At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer.
We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.
We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works.
Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT2.
This role is highly focused on enterprise program development and management of the transitional care program, associated post-acute interventions, and utilization management programs. This includes clinical interventions and guidelines that address appropriate bed day management (observation, acute, sub-acute), emergency department diversion, and other high yield interventions that appropriately reduce utilization of unnecessary healthcare resources. All aimed at reducing preventable admissions/readmissions, complications, and redundant or duplicative healthcare services. This role is a key member of our unique integrated multi-disciplinary team working in collaboration with AbsoluteCare care teams and community healthcare professionals to proactively manage a vulnerable complex population. Programmatic outcomes must adhere to industry standard clinical guidelines (MCG/InterQual), regulatory standards (NCQA), in addition to key performance indicators such as reduction in admissions/bed days, length of stay and total cost of care for our members.
This role serves as a transitional care, post-acute and utilization management subject matter expert (SME) across the company for both internal and external facing meetings and initiatives. This role will partner with counterparts on both medical, behavioral and social determinants of health teams to deliver integrated care and ensure relevant interventions are addressing all aspects of our patients' lives. This individual represents the mission, vision, and values of AbsoluteCare at all times.
Duties and Responsibilities
Develop transitional care, post-acute and utilization management program standards, practices, protocols, policies, and procedures, in accordance with applicable laws, regulatory and accreditation requirements that are consistent with most up-to-date research findings, best practices, and national professional standards to achieve excellence in patient care and transitions of care.
Leverage evidenced based guidelines such as MCG or InterQual for discharge planning and optimize appropriate level of care decisions.
Ensure high quality and timely delivery of care coordination and utilization management, incorporating NCQA standards.
Lead a transitional care management/utilization management team comprised of licensed clinical staff and unlicensed support staff.
Closely collaborate with interdisciplinary care team to deliver integrated care and address all aspects of our complex vulnerable member’s lives: medical, behavioral and social
Analyze data to successfully design, implement and measure processes that increase positive health outcomes as evidenced by overall appropriate health care cost and utilization reduction.
Oversee clinical staff development and performance that results in person-centered care planning, SMART goals, clear and consistent documentation, use of evidence-based clinical care guidelines.
Consult on best practices related to staff recruitment, screening, hiring, orienting, and training for the transitional care and utilization management team.
Consult with local market leadership on strategic alliances and collaborative relationships with other healthcare systems and providers in the region.
Act as a liaison between the executive team and the care delivery teams, including clinical and financial components of the organization, in this outcome-based care model.
Collaborate with our multi-disciplinary team to further program development, evaluate and compare effectiveness of new strategies across the organization.
Direct and coordinate internal and external agents to maintain patient safety, compliance with applicable standards, and patient rights.
Plan and supervise administrative aspects of the department, delivery of services, programs, and long-term planning to ensure adequate staffing, resources, and system support.
Work with the data analyst team to improve reporting and monitoring member engagement and outcomes.
Monitor and identify barriers within the organization related to successful patient and/or organizational goals.
Provide training within the organization for other departments within the organization.
Oversight and management of NCQA Utilization Management program.
Proven record to lead through change in a dynamic matrixed organization.
Registered Nurse with preferred Masters level degree.
Minimum of 5 years’ experience successfully leading transitional care management, post-acute interventions and utilization management programs for complex Medicaid, Medicare, and Dual-Eligible populations.
Experience with transitions of care, discharge planning, inpatient clinical care, and/or robust post-acute programs.
Vast knowledge, successful experience and proven record with care transitions and associated readmission reduction strategies.
Experience with MCG/InterQual criteria for discharge planning and post-acute care management plans.
Proven ability to analyze and leverage population health reporting to identify and successfully implement interventions that led to appropriate utilization and cost reduction.
Ability and proven record to appropriately reduce admissions/1000, readmissions/1000 and ED visits/1000.
Experience with NCQA and Delegated Utilization Management programs preferred.
Multiple settings experience (acute inpatient, SNF and home health) preferred.
Experienced in concurrent review for level of care determinations and taking action to transition to other care settings.
Experience working with vulnerable, high risk, medically complex patients with multiple comorbidities.
Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare and Dual-Eligible beneficiaries.
Excellent oral and written communication skills with ability to format and present to internal and external stakeholders.
Excellent leadership skills with proven record of developing and maintaining team morale, high productivity levels, and minimal undesirable staff attrition.
Excellent organizational and time management skills to prioritize and meet deadlines.
Knowledge and experience using multiple electronic medical records and ability to analyze and leverage their reporting capabilities.
Working knowledge of Microsoft Office Suite (Word, Outlook, PowerPoint, and Excel); and
Ability to travel up to 50%.
Active unencumbered driver’s license, with automobile insurance, reliable transportation, and ability to work in office and in the community.
Hold and maintain active driver’s license and proof of insurance in state of practice.
This job operates in the community and within a professional office environment and may operate in a remote capacity. This role requires the ability to travel national to our comprehensive care centers and inpatient facilities; and routinely uses general office equipment. Exposed to the diseases and infections of patients daily. May share workspace with other technicians and staff.
Ability to communicate clearly and exchange accurate information constantly.
Ability to remain stationary for long periods of time.
Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
Operates a motor vehicle.
Ability to occasionally move objects up to 20 lbs.
AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.
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